|Year : 2012 | Volume
| Issue : 2 | Page : 244-246
Uncommon, undeclared oesophageal foreign bodies
MI Akenroye, AT Osukoya
Departments of Ear, Nose and Throat Head and Neck Surgery, State Specialist Hospital, Akure, Ondo State, Nigeria
|Date of Acceptance||11-May-2011|
|Date of Web Publication||16-Jun-2012|
M I Akenroye
No. 3 Lafe inn way, off Oyemekun road, P O Box 3861, Akure, Ondo state
Source of Support: None, Conflict of Interest: None
| Abstract|| |
We report two cases of unusual and undeclared oesophageal foreign bodies. A small double-rounded calabash or bottle gourd Lagenaria siceraria, stuffed with traditional medicine designed to acquire spiritual power. A whole tricotyledonous kola nut Cola nitida also designed to make medicine to gain love from a woman after passing it out in stool. Each case presented with a sudden onset of total dysphagia and history of ingestion of foreign bodies was not volunteered by any despite direct questioning. Plain radiograph of the neck and chest in either case did not reveal presence of foreign body.
Both were successfully removed through rigid oesophagoscopy.
Keywords: Calabash or bottle gourd Lagenaria siceraria and whole kola nut Cola nitida, normal human, rigid oesophagoscopy, undeclared foreign body, unusual
|How to cite this article:|
Akenroye M I, Osukoya A T. Uncommon, undeclared oesophageal foreign bodies. Niger J Clin Pract 2012;15:244-6
| Introduction|| |
Foreign body ingestion forms a major part of emergencies that the otorhinolaryngologist needs to tackle all over the world. It may be deliberate or accidental.  All age groups are affected, but the incidence is higher in children below 5 years ,, and also in the very old, particularly the edentulous patients.  Children who are less than five years are particularly vulnerable because of their inquisitive nature and the tendency to explore every available cavity in their body. 
A wide variety of objects are involved. In children, common items of play including pebbles, plastics, toys, and coins are common, ,, sometimes corrosives may be mistaken for potable water by children. 
In adults, fish bones, chicken bones, bolus, meat, and dentures top the list. ,,, Magicians and psychologically unstable patients may be found with some unusual foreign bodies including needles and pins. ,
Oesophageal foreign bodies may be silent or highlight an underlying pathological condition, whereas pharyngeal foreign bodies tend to cause more problems due to interference with breathing and possibility of aspiration. 
Fatal complications have been reported in cases of impacted oesophageal foreign bodies due to late diagnosis, late referral to hospital, and mismanagement. ,
We report two cases of unusual, undeclared oesophageal foreign bodies in two apparently normal males who only gave correct history after removal of the foreign bodies.
Swallowing of whole kola nut, Cola nitida, had previously been reported by Okeowo,  but swallowing of calabash or bottle gourd, Lagenaria siceraria, has not been previously reported.
| Case Reports|| |
A case of 27-year-old male artisan (welder) who presented to us on a Sunday afternoon with a history of sudden onset of total dysphagia of about four-hour duration. He had a discomfort in the mid-chest region and was noted to spit saliva occasionally. He was otherwise physically healthy and did not display any sub mentality or psychiatric features. He denied swallowing any foreign body or corrosives.
Chest radiograph was virtually normal and barium swallow was not available locally. Unable to explain the cause of the dysphagia, rigid oesophagoscopy was discussed with the patient to which he consented.
Intraoperatively, we encountered a round brownish object at about 22 cm from upper incisor teeth.[Figure 1] An attempt to grasp it with a biting forceps created a defect on the object which eventually helped provide a point for the forceps to grasp for eventual extraction. The bottle gourd measured about 5 cm in length and 2.5 cm in its widest diameter. The procedure was largely nontraumatic and a nasogastric tube was instituted.
A discovery of a double-rounded calabash or bottle gourd, Lagenaria siceraria, stuffed with black substance was puzzling. Confronted with the extracted foreign body after recovering from anaesthesia, the patient then confessed that he swallowed the foreign body to gain spiritual powers and thought the procedure would help to push it down his stomach to achieve his aims rather than removal.
|Figure 1 : The foreign body (bottle gourd) stocked with black substance after removal|
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This was a case of a 31-year-old man who presented to our hospital early on a Sunday morning with history of total dysphagia. He was well the previous day and had his evening meals without problems. The patient was noticed to be anxious but his vital signs were within normal limits.
Apart from not being able to swallow his breakfast, he did not have any other symptoms. His clinical health status was normal. Patient denied swallowing any foreign body or corrosive and except for the obvious anxiety on his face, he looked mentally balanced.
Plain radiograph of the neck and chest did not show any significant abnormality and contrast studies were not available to explain the cause of dysphagia; hence, patient was offered rigid oesophagoscopy to which he consented.
Intraoperatively, we encountered a whole kola nut, Cola nitida, at 25 cm from upper incisor teeth which was very difficult to remove (piece meal at first until it split into three cotyledons) and the rest became easier to remove.[Figure 2] Each intact kola nut cotyledon measured 1.2 cm and after tying the three pieces together had a diameter of 2.5 cm. Nasogastric tube was instituted and maintained for about 48 hours to ensure there was no evidence of perforation. The patient made full recovery without complication.
Confronted with the finding after recovering from anaesthesia, the patient humbly asked for privacy to discuss the issue, only to confess to one of us about his deep love for a lady who just would not agree to his proposal. He was asked to swallow the whole tricotyledonous kola nut, Cola nitida, overnight by a traditional medicine man and after passing it in stool; he was to use it to prepare the medicine for love to be given to the lady. The plan never succeeded.
| Discussion|| |
Foreign bodies in the oesophagus constitute one of the commonest emergencies the Otolaryngologist needs to deal with from time to time. Foreign bodies could be classified as food or true foreign bodies. 
The oesophagus narrows at three sites: The cricopharynx (C6), at the level of the aortic arch (T4), and the gastro-oesophageal junction (T10). Foreign bodies usually lodge at any of these sites. , Objects greater than 2 cm in diameter has difficulty traversing the normal adult oesophagus. 
Foreign bodies in oesophagus affects both children and adult but the objects involved usually differ in the two groups. In children below five years, these include coins, plastics, parts of toys, play items, and sometimes corrosives. , Swallowing of whole kola nut, Cola nitida, has been reported by Okeowo  and pins/needles were also reported in adults by other workers. ,, Fish hook impaction was reported by Okhakhu and Ogisi  and all sorts of other miscellaneous objects have been seen in mentally disturbed patients and people involved in magical display and sword swallowers. 
Patients commonly complain of dysphagia, odynophagia, and chest pain. Excessive salivation occurs particularly when the obstruction is at the upper end of oesophagus and is total. If left untreated, other symptoms arising from complication of foreign body may arise depending on the nature of the object. These include aspiration pneumonitis, perforation, mediastinitis, lung abscess, peritonitis, , and these are sometimes fatal. ,
A positive history of nature of the foreign body ingested is usually a useful guide in planning the removal and older children and adults usually render such information. However, children below 18 months of age may present a peculiar problem requiring thorough investigation for correct diagnosis. When an adult patient fails to give correct history as in the case of these patients, diagnosis in our setting becomes more difficult. Barium swallow, computed tomography, and magnetic resonance imaging would be useful tools where available.
Urgent endoscopic removal is required when a sharp object is ingested or if evidence of high-grade obstruction is present. Foreign bodies may be removed using various instruments or by push technique.  The push method would deliver the foreign body to the stomach, but there is increased risk of perforation. 
| Conclusion|| |
The two cases reported here were adults whose actions were deliberate. Because of reasons which they presumed not to be socially acceptable to the public, the history of ingestion of foreign bodies was deliberately concealed and initially denied.
We would like to point out to practitioners in this region that a case of sudden onset of dysphagia without a positive history of ingestion of foreign body does not exclude foreign body and a negative finding on X-rays does not exclude oesophagoscopy which must be considered when there is strong enough clinical evidence of oesophageal obstruction even in apparently normal individuals.
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[Figure 1], [Figure 2]
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